内窥镜后路下腰椎间盘切除术解剖与临床研究

目的：为显微内窥镜下腰椎间盘切除术提供解剖学基础,提高手术效果.方法：20具成人L3～S1段尸体标本,去除腰椎畸形凸出标本,正中矢状锯开,观测椎板、黄韧带、神经根与椎间盘之间关系.临床应用椎间盘镜（MED）治疗腰椎间盘突出56例.结果：L3～4椎间盘被L3椎板遮挡最多,L4～5椎间盘次之,而L5～S1椎间盘没有或仅有少许被L5椎板遮挡 L3～4椎间盘下缘均在L4神经根肩部上方,L4～5椎间盘下缘多在L5神经根肩部、腋部之间,而L5～S1椎间盘多在S1神经根腋部下方 临床随访5～8个月,根据NaKai分级,优46例,良9例,可1例.优良率98.2% .结论：严格把握适应证、熟练掌握腰椎各节段解剖特点,是提高MED手术成功率和减少并发症的关键.     

Prognostic value of cervical ligamentum flavum thickness as a morphological parameter to predict cervical stenosis

One of major causes of cervical central stenosis (CCS) is thickened change of cervical ligament flavum (CLF). The association of a morphological parameter called cervical ligament flavum thickness (CLFT) with CCS has not been reported yet. Thus, the purpose of this research was to investigate the relationship between CCS and CFJT.Data were obtained from 88 patients with CCS. A total of 87 normal controls also underwent cervical spine magnetic resonance imaging (CSMRI). All subjects underwent axial T2-weighted CSMRI. Using our picture archiving and communications system, thickness of ligament flavum of the cervical spine at C6/7 level was analyzed.The mean CLFT was 1.41 ± 0.24 mm in normal subjects and 2.09 ± 0.39 mm in patients with CCS. The CCS group was found to have significantly (P < .001) higher rate of CLFT than normal subjects. ROC curves were used to assess the usefulness of CLFT as a predictor of CCS. In the CCS group, the best practical cut off-point of CLFT was 1.71 mm (sensitivity = 90.9%; specificity = 90.8%), with AUC of 0.94 (95% confidence interval: 0.90--0.98).Greater CLFT values were associated with greater possibility of CCS. Thus, treating physician should carefully examine CLFT, as it can help diagnose CCS.     

Computer-assisted minimally invasive spine surgery for resection of ossification of the ligamentum flavum in the thoracic spine

Background Ossification of the ligamentum flavum （OLF） has been widely recognized as one of the main causes of thoracic spinal canal stenosis and thoracic myelopathy.Decompression is the only effective strategy for treating thoracic myelopathy caused by OLF.The purpose of this study was to describe the clinical outcomes of computer-assisted minimally invasive spine surgery （CAMISS） for posterior decompression in patients with thoracic myelopathy caused by OLF.Methods In all cases,the surgical procedure was performed with the assistance of an intraoperative three-dimensional navigation system.Decompression of the spinal cord was performed with a high-speed drill; the supraspinal ligaments and spinous process were partially preserved.The outcomes were evaluated by a modified Japanese Orthopedic Association （JOA） scoring system and recovery rates.Results The mean duration of follow-up for the 14 cases was 3.9 years.All patients experienced neurological recovery,the mean JOA score improving from 6.1 points preoperatively to 8.6 points at final follow-up and the mean rate of recovery being 52.7% （excellent in two cases,good in eight,fair in three,and unchanged in one）.Conclusion CAMISS is a safe and effective procedure for resection of the OLF in the thoracic spine.     

Cardiac-MRI demonstration of the ligamentum arteriosum in a case of right aortic arch with aberrant left subclavian artery

Right-sided aortic arch with aberrant left subclavian artery (RAA/ALSC) is the second most common mediastinal complete vascular ring. Adult presentation of dysphagia lusoria due to a RAA/ALSC is uncommon with fewer than 25 cases reported in the world literature. The left lateral portion of this vascular ring is not a vessel, but an atretic ductus arteriosus, the ligamentum arteriosum, which has been identified in different cases as the major cause of tracheo-esophageal impingement. Surgical division of the ligamentum arteriosum allows the vessels to assume a less constricting pattern decreasing dysphagic symptoms. Clear visualization of the ligamentum arteriosum by diagnostic imaging has not been obtained in previously reported cases. We demonstrated, using magnetic resonance imaging, the location and the complete course of a left-sided ligamentum arteriosum in a patient with adult-onset dysphagia due to a RAA/ALSC with a small Kommerell’ s diverticulum, providing, during the same session, a complete assessment of both mediastinal vascular abnormalities and esophageal impingement sites.     

Symptomatic ganglion cyst of ligamentum flavum as a late complication of lumbar fixation

We report the case of a 72-year-old man who underwent surgery for a mobile spondylolisthesis L4-L5. Six months later, magnetic resonance imaging revealed an extradural cyst of the ligamentum flavum at L5-S1, which was then removed. Histological examination revealed a ganglion cyst of the ligamentum flavum. Cyst formation could be explained primarily according to the natural history of chronic degenerative disease of spine elements. Nevertheless, we could also consider the cyst formation as demonstrative of an adjacent segment syndrome: hypermobility of the L5-S1 segment just below three fixed vertebral segments would have triggered the mechanical stress necessary for L5-S1 ligamentum flavum degeneration.     

腰椎管狭窄症肥厚黄韧带的病理学研究及其与腰椎过度伸屈运动的相关性

目的:观察弹性纤维与胶原在正常黄韧带和肥厚黄韧带内不同应力部位的变化情况,探讨腰椎过度屈伸活动造成黄韧带损伤后其内部胶原过度表达所致纤维化与黄韧带厚度的相关性。方法:腰椎手术中收集黄韧带标本20例,其中10例来自腰椎间盘突出患者正常厚度黄韧带,设为对照组(n=10);10例来自因黄韧带肥厚导致腰椎管狭窄患者的黄韧带(n=10)。对比正常黄韧带和肥厚黄韧带及肥厚黄韧带不同应力部位(腹侧部、中间部、背侧部)之间的弹性纤维和胶原表达差异;鉴定表达胶原类型;分析黄韧带厚度与黄韧带纤维化程度的相关性。结果:两组患者黄韧带厚度存在显著性差异(P0.01);肥厚黄韧带内弹性纤维减少、胶原表达增多,纤维化程度明显高于正常黄韧带组;应力集中的肥厚黄韧带背侧部胶原表达增多、纤维化程度明显高于中间部和腹侧部;过度表达的胶原为Ⅰ型和Ⅲ型胶原;黄韧带厚度与黄韧带纤维化程度呈显著正相关(r=0.77)。结论:弹性纤维减少、Ⅰ型和Ⅲ型胶原表达增多形成纤维化是导致黄韧带肥厚造成腰椎管狭窄的主要病因,在应力集中的黄韧带背侧部表达更显著,脊柱康复运动应避免过度腰椎屈伸活动。     

氟骨症性胸椎黄韧带骨化手术治疗

目的：回顾分析了18例氟骨症性椎黄韧带骨化的诊断和手术治疗特点,方法：1988－1999年收治的18例氟骨症性胸椎黄韧带骨化患,叙述了临床表现,影像检查结果（X光平片,脊髓造影,CT及MRI）,手术治疗,结果：18例均经手术治疗,手术节段3－7节,平均5．2节,随诊时间均超过1年,优良率占73．3％。结论：1）氟骨症性胸椎黄韧带骨化手术治疗是有效的,（2）氟骨症性胸椎黄韧带骨化患病复杂,临床表现多样,术前定位依靠详细的物理检查和必要的特殊检查,如MRI,脊髓造影等。（3）手术为后路椎板切除＋关节突部分切除术,术前准备要充分,术中操作要轻柔,对多节段受累受取分次手术或分段手术。     

Progress on Clinical Characteristics and Identification of Location of Thoracic Ossification of the Ligamentum Flavum

Thoracic ossification of the ligamentum flavum (TOLF) is the most common cause for thoracic spinal stenosis. TOLF is usually complicated by thoracic disc herniation, ossi?cation of the posterior longitudinal ligament and degenerative spinal diseases such as cervical spondylosis and lumbar spinal stenosis, and the ossi?cation also usually has a discontinuous or continuous multi‐segment distribution. The resultant superposition of several symptoms makes the clinical manifestations complex. Currently, the diagnosis of TOLF depends mainly on the patient's symptoms, physical examination and thoracic CT and MRI examinations. Identification of the location of TOLF depends more on the doctor's subjective judgement. Diagnostic problems are related to the specific region and level of surgical decompression: if the extent of decompression is insufficient, the treatment is inadequate, resulting in residual symptoms. Obversely, unnecessary trauma and a various complications will occur if the decompression is too extensive. Hence, the clinical features and process of diagnosis, especially the means of identifying the location, still require further improvement. It is necessary to establish a simple and accurate means of identifying the segment of TOLF that is responsible for the neurologic deficit: a number of spinal surgeons have been working hard on this. This article will provided an overview of the clinical features of TOLF and the related problems of clinical identification of the location of the segment causing the neurological deficit. The relationship between the imaging manifestations and clinical characteristics still need to be explored with the aim of establishing a simple and precise method for determining precisely whether TOLF is related to spinal cord injury or not, thus reducing surgical trauma and achieving an optimal prognosis.     

Lumbar spinal stenosis in a young individual as a result of ligamantum flavum ossification: A case report

INTRODUCTIONSymtomatic lumbar ligamantum flavum calcification is quite rare in the young age group.PRESENTATION OF CASEThe authors report a case of young adult with diagnosis of lumbar spinal stenosis, presenting with leg pain and neurological deficits. Computerized tomography (CT) scan and magnetic resonance (MR) imaging studies revealed ossification of the ligamantum flavum as the causative factor of the disease and the patient recovered completely after the decompressive operation.DISCUSSIONIt is emphasized that attention should be given to this rare etiological factor of lumbar spinal stenosis.CONCLUSIONComplete relief can be achieved with early and adequate surgery.     

Reconstruction of the lateral ankle ligaments using the anterior half of peroneus longus tendon graft

Background

This study aimed to report our institution’s experience in the treatment of chronic lateral ankle instability using the anterior half of the peroneus longus tendon (AHPLT) to reconstruct the lateral ligament.